Roy Kinnear House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.
This is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The provider assessed people’s health, care, wellbeing, and communication needs when they first moved into the service. For example, we saw a detailed initial assessment for a person transitioning from an education setting. This involved input from multidisciplinary teams and family members and covered key risks such as epilepsy and mobility. Staff demonstrated awareness of people’s preferences and routines, and initial care plans included person-centred goals.

However, care records did not clearly or comprehensively support ongoing reviews or show appropriate action taken in response to changes in people’s needs. Documentation lacked structure and often failed to demonstrate how care had been adapted over time.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.Staff used clinical observations and nationally recognised tools to monitor people’s health needs. Records showed that vital signs, weight, and skin integrity were routinely monitored. Where people were at risk of choking or had other complex health conditions, relevant clinical protocols were in place and followed.

Care plans reflected input from external health professionals, including dietitians, speech and language therapists (SALT), epilepsy nurses, physiotherapists, and bowel care teams. This guidance was included in people’s support plans and covered areas such as Percutaneous Endoscopic Gastrostomy feeding (PEG), posture management, and safe swallowing techniques.

Nutritional needs were met in line with national guidance. People’s weights were recorded regularly, and feeding regimes were documented where required. There was evidence of dietetic input for people with complex feeding needs.

Staff demonstrated an understanding of people’s health conditions, and the actions needed to manage associated risks. This included awareness of bowel care routines, seizure management, and support with sensory regulation. Staff also demonstrated an understanding of how to support people who required oxygen, including recognising when to escalate concerns. In addition, staff were aware of behaviour support plans and described approaches used to de-escalate and respond to triggers in line with individual needs.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff worked in collaboration with external professionals to meet people’s needs and promote continuity of care.

When people required hospital care, staff ensured they were supported with a hospital passport and arranged for them to be seen by clinicians familiar with their needs. Staff told us this supported effective communication and reduced distress. Hospital discharges were also managed with input from families and health professionals.

The provider had working relationships with the local Integrated Care Board (ICB) and NHS professionals. Staff told us that 1 hospital had offered to support with specialist training, though this had not yet taken place. We were told this was being arranged to enhance staff skills in managing complex care needs.

Communication between team members appeared effective on the day of the visit. Staff shared information during handovers.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to live healthier lives by ensuring access to healthcare professionals such as general practitioners, district nurses, opticians and dentists. Appointments were arranged as needed and families were kept informed. Staff supported people to attend regular health reviews and appointments. A family member told us, “There have been some notable occasions when care staff have raised issues with me regarding my relative’s care… which shows that the care staff are both thoughtful and proactive.” A healthcare professional also said, “Staff at Roy Kinnear House have been responsive to the Integrated Care Board (ICB) communication and engaged well during visits to the property. If there is a change in care needs, physically or medically, I am confident the nursing oversight will be able to manage those needs without requirement for unnecessary extended hospital admissions”.

However, we found that the recording of health appointments was inconsistent. In some cases, documentation was limited or missing altogether. This affected the service’s ability to track follow-up care or demonstrate that timely and appropriate action had been taken. The provider recognised these discrepancies in their documentation and had launched a digital care system to improve this.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service did not have effective systems in place to monitor and evaluate care outcomes. We found that daily records and care notes lacked structure and consistency. Notes were often generic, repetitive across different people, and failed to reflect people’s specific needs, experiences, or responses to care interventions. This limited the ability of staff and leaders to track progress, identify trends, or ensure care was outcome focused. The provider did not always routinely monitor people’s care and treatment to continuously improve it.

We noted one example where a person’s bowel management plan stated that an intervention should be initiated if there were no bowel movement for 3 days. In that month, the intervention was not carried out as stated in the guidance and the bowel chart showed there had been no bowel movement.

The provider had systems to monitor people's health conditions and respond to clinical needs. However, not all aspects of care delivery and documentation were aligned with evidence-based best practice. For example, there was no evidence that care records or daily diary notes were being audited. This meant that any inaccuracies, gaps, or missed opportunities to improve support may not have been detected.

A lack of robust documentation also affected the service’s ability to demonstrate how it responded to changes in people’s needs. For example, we reviewed behaviour monitoring charts that had been completed. While these charts were in place, they appeared to be filled in routinely without clear evidence of clinical interpretation or action in response to any patterns or concerns recorded. There was no indication that the information gathered was being used to inform care reviews or guide proactive support strategies

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.
Where people lacked capacity to make specific decisions, staff involved family members in decision-making where appropriate. Deprivation of Liberty Safeguards (DoLS) authorisations were in place. However, some had expired at the time of the assessment but the provider had taken action to request reviews.

Staff had received training on the Mental Capacity Act 2005 (MCA) and demonstrated a clear understanding of its principles. Some care plans included assessments of capacity relating to specific decisions.

However, there was no documented evidence of best interest decision meetings or formal records to support decisions made on behalf of people who lacked capacity. The provider stated they were in the process of reviewing and updating care records to ensure these were accurate and consistent.

In addition, where people lacked capacity to make specific decisions, there was no evidence of best interest decision meetings being held or recorded. Records did not clearly demonstrate how decisions were made on behalf of people, or how the provider established that the person lacked capacity in line with the Mental Capacity Act.